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Paragraphs: 11.1 - 11.9
| 11.10 - 11.21 | 11.22 -
11.31 | 11.32 - 11.39
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11.1
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In the two preceding sections, I have dealt in some detail with
the various deficiencies in the care that Victoria received from
the two hospitals in which she was an inpatient during the summer
of 1999. As my analysis of the services that Victoria received in
the Central Middlesex Hospital and the North Middlesex Hospital
went on, I felt it was necessary to expand on two issues in particular.
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11.2
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The first issue is the way in which information obtained about
Victoria while she was in hospital was managed, recorded and shared.
The second issue is the status and priority given to child protection
in the context of paediatric medicine.
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11.3
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The regularity with which these issues arose, and their centrality
to a proper understanding of what went wrong in the handling of
Victoria's case by these two hospitals, mean that these issues are
worth separate analysis. That is the purpose of this section.
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11.4
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There was enough information about Victoria readily available to
the staff caring for her at the Central Middlesex Hospital and the
North Middlesex Hospital for them to have reached a proper appreciation
of the danger that she was in. What is more, most if not all of
this information came to the attention of at least one of the health
professionals concerned. As is clear from the preceding sections,
the findings and observations of the doctors and nurses involved
in Victoria's care produce a compelling picture of a child at very
serious risk. One of the greatest tragedies of Victoria's case is
that such ineffective use of this vital information was made at
the time.
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11.5
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There was a consistent failure by doctors and nurses at both hospitals
to record information comprehensively, to record and share concerns,
and to record and complete the actions that the concerns prompted.
Worst of all, nobody noticed when things were not being done.
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11.6
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I set out below what I consider to be the most glaring examples
of poor practice in relation to these aspects of Victoria's care.
They are by no means exhaustive and they are not restricted to any
particular staff group - senior or junior, doctor or nurse. They
demonstrate a generalised failure at both hospitals to appreciate
the importance of efficient information management as an integral
part of Victoria's care. They also show a failure to recognise that
competence in information management is no less critical in cases
of deliberate harm to a child, than competence in diagnosis or competence
in treatment.
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11.7
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The first and most obvious deficiency in the way information was
managed by staff at the hospitals was the failure to record their
observations and concerns. The periods that Victoria spent in hospital
are littered with instances of important information failing to
find its way into her notes. Nurse after nurse, from the North Middlesex
Hospital in particular, came before me to describe extremely concerning
injuries or behaviour about which the records completed at the time
are completely silent. Dr Simone Forlee, as discussed in section
10, was extremely perceptive in her initial assessment of Victoria
when she was first admitted. But the first time that any of these
valuable insights were written down was when she prepared her statement
for this Inquiry.
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11.8
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The wearying regularity with which Counsel to the Inquiry was obliged
to ask the simple question "Why did you not record that in the notes?",
leads me to conclude that the amount of useful information about
Victoria that was recorded by the professionals charged with her
care while she was in hospital, is far exceeded by the amount of
useful information that was not.
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11.9
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I express myself in forceful terms on this issue because I wish
it to be clearly understood that I regard the keeping of proper
notes and the accurate recording of concerns felt about a child
as being a fundamental aspect of basic professional competence.
At one stage, the representative of the NHS witnesses told me that
pointing out to health professionals that they should write better
notes "is pushing at an open door". If that was intended to convey
that this is a well-recognised problem of which doctors and nurses
have long been aware, then it is time that it was addressed.
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Paragraphs: 11.1 -
11.9 | 11.10 - 11.21 | 11.22
- 11.31 | 11.32 - 11.39
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11.10
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The next information management deficiency illustrated by Victoria's
case is that the useful information that was recorded was kept in
a variety of different places.
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11.11
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During the period that Victoria spent on Rainbow ward, information
about children was recorded in a number of different locations -
the hospital notes, the medico- legal folder containing the child
protection forms, the critical incident log, the psychosocial meeting
book, and the ward allocation book. Such a fragmented recording
system significantly inhibited the sharing of important information.
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11.12
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The recording of information about a particular child in a number
of different places can allow inconsistencies to arise and persist.
Chronology is vital in medical records because diagnoses change
and more information becomes available. When notes are held in a
variety of different places, the difficulties in ensuring that the
most up-to-date information is readily obtainable are clear.
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11.13
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There are many examples in Victoria's hospital care where doctors
and nurses did not seek information because they assumed they had
a full picture, or were simply ignorant that their knowledge base
was incomplete. For example, Dr Justin Richardson did not see the
set of completed child protection forms about Victoria in the ward's
medico-legal folder when he carried out his ward round on 26 July
1999.
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11.14
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On numerous occasions during the course of the evidence, the answer
that was given to the question of why a particular observation or
intended action was not recorded in the notes, was that the need
to do so had been removed by the fact that the information had been
"handed over verbally".
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11.15
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For example, Dr Forlee felt that Victoria should have been seen
in the absence of Kouao and with the aid of a French interpreter.
She believed she would have suggested this on her ward round. Unfortunately,
the suggested action was not recorded and Victoria never was spoken
to alone with the assistance of a French interpreter.
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11.16
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Similarly, Dr Ekundayo Ajayi-Obe told me that she remembered telling
"someone" that she had a child on the ward whom she suspected to
be suffering from "non- accidental injury". However, the fact that
she did not record to whom she spoke or what she said made it impossible
to assess what should have been done as a result of this conversation,
or by whom.
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11.17
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Verbal handovers and referrals, either face-to-face or on the telephone,
carry with them a high risk of ambiguous transfer of information
and the creation of false confidence that actions have been understood
and will be carried out. Such verbal exchanges alone, unsupported
by clear documentation, undermine high-quality care.
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11.18
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In the context of a busy paediatric ward it may often be the case
that a senior doctor will be forced, by virtue of the other calls
on his or her time, to delegate a particular task to another member
of the medical staff. When such delegation occurs, it is vital that
a clear note is made of the identity of the person to whom responsibility
for the task has been transferred. The inevitable consequence of
not doing so, is that nobody is clear who has responsibility and
the task does not get done.
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11.19
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This was the case with the examination of Victoria while she was
in the North Middlesex Hospital. Dr Mary Rossiter believed she delegated
the responsibility for documenting the marks on Victoria's body
and for a full examination to the senior house officer taking over
from Dr Forlee on the morning of 25 July 1999 whom she thought to
be Dr David Reynders. As it happened, Dr Reynders was not on duty
that day. When Dr Reynders did finally come to see Victoria, he
was under the impression that all he was required to do was document
Victoria's injuries on a body map.
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11.20
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The lack of any system on the ward for the proper assigning of
responsibility for particular tasks was further illustrated by the
evidence of Dr Forlee. When asked how each of the steps in an action
plan formulated at a ward round would be taken forward, she explained
that the usual procedure was that two senior house officers would
be present and that following the ward round "it would be fairly
random who wrote in the notes".
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11.21
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There was apparently no system on Rainbow ward to ensure that actions
to be completed were recorded, there was no system for assigning
responsibility for carrying out the actions and there was no mechanism
to alert anyone if the actions were not completed.
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Paragraphs: 11.1 -
11.9 | 11.10 - 11.21 | 11.22
- 11.31 | 11.32 - 11.39
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11.22
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In circumstances in which staff work under severe pressure of time
and where a number of different individuals will have responsibility
for the care of a particular child during a relatively short period,
the dangers of putting off necessary tasks to another day are self-evident.
This was illustrated on a number of occasions during the course
of Victoria's stay in the North Middlesex Hospital and the Central
Middlesex Hospital. The following are good examples:
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11.23
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First, Dr Forlee decided to defer a full examination of Victoria
to a later stage after her admission. She felt that such an examination
would best be performed on the ward under the supervision of a more
experienced paediatrician than herself.
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11.24
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Second, later the same day, Dr Olutoyin Banjoko decided that further
questioning of Kouao should be done in a more controlled setting
where there was a consultant and other members of the child protection
team present. She also thought it was not morally right to subject
Victoria to an examination that evening, taking into account both
the lateness of the hour and the fact that Victoria was to be seen
by Dr Rossiter the next day.
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11.25
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Third, similarly at the Central Middlesex Hospital, Dr Ruby Schwartz
put off seeing Victoria alone because she thought a full investigation
would be undertaken by social services and she did not want to compromise
any interview they might have wanted to have with Victoria. However,
she accepted that with hindsight, seeing Victoria alone would have
been a sensible thing to do.
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11.26
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None of the deferred actions set out above subsequently took place.
Victoria was never seen alone, Kouao was never interviewed. No thorough
examination of Victoria was ever conducted at the North Middlesex
Hospital. At least part of the explanation for these omissions lies,
in my view, in the fact that the necessary steps were not taken
at the time they were identified and, instead, were put off until
another day.
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11.27
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Immediate action may not always be either possible or desirable.
Deferring actions either out of consideration for the patient or
as a result of clinician workload may be understandable. But failure
to record that the action has been deferred and failure to check
that the action is completed is virtually guaranteed to ensure it
will never get done. Responsibility for the action must remain with
the deferring clinician until either the action is completed or
until responsibility for the action is handed over unambiguously
to another clinician and so documented.
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11.28
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Victoria's case contains numerous examples of doctors and nurses
making assumptions about either what had already been done or what
others were going to do.
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11.29
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An example of the first is Dr Saji Alexander's assumption, when
he conducted his ward round, that a full and thorough examination
of Victoria's injuries was unnecessary, given the fact that a record
had been made of them on the body maps. The result was that he did
not do one himself. He never sought to check his assumption that
Victoria had been fully examined. Had he done so, he would have
discovered that it was mistaken.
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11.30
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As to the second, there were a number of instances where medical
and nursing staff made assumptions about the steps that social services
would take on Victoria's case. For example, Dr Rossiter took no
other action following her telephone conversation with Lisa Arthurworrey
because she did not think it was a prelude to Victoria's discharge.
She thought she would be getting feedback from social services,
regrouping at the next psychosocial meeting, and then after that
start thinking about Victoria going home. However, her expectations
were not realised and Victoria ended up being discharged without
her knowledge.
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11.31
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Presumptions and expectations that others will take appropriate
actions may or may not be reasonable in any given situation, but
they must always be accompanied by checking that the assumptions
are correct and expectations have been met.
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Paragraphs: 11.1 -
11.9 | 11.10 - 11.21 | 11.22
- 11.31 | 11.32 - 11.39
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11.32
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Finally, there were frequent instances when a necessary action
was clearly identified in the notes, but simply did not take place
afterwards. For example, Dr Reynders wrote up the note following
Dr Rossiter's ward round on 1 August 1999, when it was recorded
that an urgent psychiatric assessment was needed. No psychiatric
assessment ever took place.
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11.33
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Another example is provided by the note of the psychosocial meeting
in the book in the psychiatry department. The note recorded that
Dr Rossiter would examine Victoria. This was not done. Dr Rossiter
was busy with other commitments that week and was, therefore, puzzled
by the note. Even when an action was appropriately recorded, there
was no system in place to ensure that the action was completed.
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11.34
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Many of the criticisms made above deal with the failure to record
important information in the notes. They are based upon the assumption
that once an action is clearly identified and recorded as necessary,
it is more likely to take place. Therefore, it is profoundly disturbing
to find instances in Victoria's case which demonstrate that even
the clear recording that a particular step was necessary was no
guarantee that it would take place.
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11.35
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In the paragraphs above I have set out some examples of where failure
to record and share information, and to record, carry through and
check actions, significantly inhibited the efficient management
of Victoria's care. The context of these examples was a lack of
any system at both hospitals robust enough to have prevented these
information management failures from occurring, and resilient enough
to have survived the consequences of a human error once it occurred.
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11.36
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The accurate and efficient recording of information cannot be left
solely to the individual diligence of the doctors and nurses concerned.
They must be supported by a clear system that minimises the risk
of mistakes and provides a mechanism for recognising mistakes when
they occur. The greater pressures are on staff, the greater the
need for a system to support them. The busier the organisation,
the more important it is to have a system that ensures agreed actions
are recorded and completed.
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11.37
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The management of Victoria's care at the Central Middlesex Hospital
and the North Middlesex Hospital was full of inadequate and ambiguous
recording of information and actions, deferred actions, assumptions
and expectations that things 'would happen' or be done by 'someone'
or others 'at a later stage'. There were numerous failures to ensure
that things that someone thought 'would happen' did happen. Victoria's
case clearly demonstrates the need for doctors and nurses to document
information, actions and referrals consistently and unambiguously,
to share that information, and to ensure subsequently that what
has been agreed is carried through.
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11.38
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In my view, many of the deficiencies in the way in which information
about Victoria was managed by hospital staff could have been avoided
if a few basic systems had been in place to provide some logical
coherence and clear direction for the way in which information should
have been handled. Something as simple as a single action list in
Victoria's notes readily available to all those involved in her
care may well have ensured that numerous important tasks took place,
which, in the event, fell by the wayside.
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11.39
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Although the evidence that I heard on these matters was restricted
to the working practices of the staff at two hospitals only, I am
concerned that it is representative of an institutionalised failure
within the health services to properly manage information and to
give that task the prominence and attention it deserves. In order
to address this issue, I make the following recommendations:
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Recommendation
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Within a given location, health professionals should work from
a single set of records for each child.
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Recommendation
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During the course of a ward round, when assessing a child about
whom there are concerns about deliberate harm, the doctor conducting
the ward round should ensure that all available information is reviewed
and taken account of before decisions on the future management of
the child's case are taken.
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Recommendation
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When a child for whom there are concerns about deliberate harm
is admitted to hospital, a record must be made in the hospital notes
of all face-to- face discussions (including medical and nursing
'handover') and telephone conversations relating to the care of
the child, and of all decisions made during such conversations.
In addition, a record must be made of who is responsible for carrying
out any actions agreed during such conversations.
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Recommendation
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Hospital chief executives must introduce systems to ensure that
actions agreed in relation to the care of a child about whom there
are concerns of deliberate harm are recorded, carried through and
checked for completion.
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Recommendation
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The Department of Health should examine the feasibility of bringing
the care of children about whom there are concerns about deliberate
harm within the framework of clinical governance.
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